A&E needs total system overhaul if it's to cope, says hospital which revolutionised its emergency care

In the week that overstretched emergency departments up and down the country issue warnings that they are in crisis, The Telegraph gains exclusive access to Luton and Dunstable Hospital, where staff are finding a new approach to emergency care is getting brilliant results.

It’s 7pm at Luton and Dunstable Hospital’s Accident and Emergency department, and in the Resus area - where the most at-risk people are wheeled straight from ambulances into beds to be given immediate, lifesaving treatment - every one of the eight bays is filled. The cornflower blue curtains whip open and closed as nurses dash between the bays, tending to patients. In one bed lies a middle aged woman covered in terrible burns after accidentally spilling the contents of a hot water bottle over herself. In another, a girl in her twenties who has been fitting throughout the day is curled in a ball, her worried mother and older brother flanking her bed. A black phone on the wall rings with a pre alert from an ambulance crew. The senior charge nurse answers, furiously taking down notes. “I’m going to need my Bay One back!” he calls to his team, who immediately spring into action. There is a stroke victim coming in who will need to take priority, meaning one of the patients will have to be moved elsewhere, and fast, so the specialist stroke team can come in.

This is the busiest time of the day in Luton and Dunstable A&E. It is frantic and noisy, but never once do the crowded waiting room, the Resus area, or the inpatient wards descend into anything resembling chaos. This, let’s be clear, is a unique state of affairs. But it’s par for the course at the A&E unit hailed by health secretary Jeremy Hunt as an inspiration to emergency departments throughout the country.

Senior charge nurse John Scudder instructs his team of nurses in the Resus area of A&ECredit:
Telegraph/Julian Simmonds

In a week which has seen emergency departments slammed for failing to meet targets to see people within the four-hour time frame, the efficiency with which Luton and Dunstable (L&D) pulls off its emergency care is no mean feat. 65 hospital trusts last week issued warnings that they were under heavy pressures, with almost half of trusts declaring one of the two highest possible states of alert, causing health officials to declare a “national emergency”.

So where does the blame lie? Is it, as Hunt says, down to a “rising tide” of low-risk patients needlessly clogging up A&E departments, leaving units “extremely fragile”? Should the onus be on GP surgeries to shoulder the burden? On Friday, Theresa May announced an attempt to relieve the pressure on crisis-hit A&E units by forcing surgeries to open from 8am to 8pm seven days a week unless they can prove there is not enough demand in their area - or face cuts.

Or is it, as the senior team at L&D firmly believe, that our emergency units are in dire need of a complete system overhaul.

Lead nurse Giovanna Healy, in the A&E department at Luton and Dunstable HospitalCredit:
Telegraph/Julian Simmonds

Dr David Kirby, senior consultant in emergency care at L&D, explains how over the past nine years, his department has undergone a crucial about-turn in terms of its culture and administrative practice. “In 2008, this trust was scraping the barrel of performance in the metric of the four hour indicator,” he tells me, as we walk the halls of the department where he has worked on and off throughout his entire 20-year career. “We were in the pits, and that was through a combination of many things. The brief from the local SHA (Social Health Authority) at the time was: ‘This needs to be fixed’.”

Nurses, junior doctors and support staff rush in and out of cubicles around us as Dr Kirby explains that over the past nine years the trust has invested in “refining processes” like its bed management system and opening a dedicated on site GP surgery. “There is no escaping the fact that getting to where we are today has cost money. We get income on a case by case basis, so the more patients we see, the more income we have.

“Our money has been used to refine our processes, create space in which to see patients, and increase staff.

“In the past ten years we’ve doubled our nursing staff and medical staff, and increased our consultant staff from three to ten. We also have a surge ward, which we can open if we need the extra space.”

An onsite GP surgery - which only services the hospital, open from 8am to midnight - is, he says, one of the chief reasons they are able to run smoothly in spite of a surge in people coming to A&E rather than going to their own GP. This is made possible by a system called “streaming”, which Dr Kirby believes is unique to his unit.

“When a person walks into our waiting room, the first person they will meet is a streaming nurse. They will assess immediately whether or not you actually need to be in hospital.

“If they decide you don’t, a receptionist will book you into the GP software, and you walk the 50 or so yards over to the surgery.

“Of the 140,000 people that come here every year, around 40,000 will be sent there. That group of patients - who do not have injuries or illnesses we need to admit to hospital - won’t ever get a bed here, so that group doesn’t impact on flow in our hospital.”

The operations centre at Luton and Dunstable HospitalCredit:
Telegraph/Julian Simmonds

It’s then up to the well-oiled machine which is the L&D administrative team to make sure there are enough beds for those in need. Director of Operations, Marian Collict, shows me to the operations centre, where clinical and support staff wage a daily battle, balancing the flow of patients with limited beds. Standing in the nerve centre of the emergency unit feels rather like being in the cockpit of an airplane, so covered are the walls with screens tracking every in and out.

Crucial to the operation is a recently added and constantly updating screen which shows who is currently occupying beds and who is waiting to be discharged. “I have no idea how some hospitals cope by doing the bed management on paper,” she says.

The vast majority of people on the digital grid are over 70 - not unusual these days, says Marian - exposing another of the problems facing A&E departments throughout the country, as an ageing population with complex medical needs fill our hospital beds at an ever increasing rate. It’s why L&D have proposed a pilot scheme to help dilute the issue in their own catchment area - which stretches from Luton into South Bedfordshire, Hertfordshire and Buckinghamshire. The trust wants to bring medical care into nursing homes to cut down on the number of ill-equipped homes calling an ambulance every time a resident is ill.

David Kirby, a senior consultant at Luton and Dunstable HospitalCredit:
Telegraph/Julian Simmonds

“Bringing an elderly person into hospital from a care home can be so distressing,” Marian tells me. “And often what they really needed was for someone to assess them and deliver some treatment in that setting. The system is not set up to be able to do that.

“We’re proposing working with the ambulance trust so that when a care home calls an ambulance and that person is not urgent, that would be diverted to this new team, a nurse practitioner would go out, assess the patient, link into a clinician in the hospital and deliver treatment without them having to come in.”

The pilot - due to start in February - will last three months, and if successful could instigate a major shift in community care for the elderly, with more and more hospital trusts seeking funding for such teams.

Dr Kirby explains how now that his unit has a model of how to run efficiently, it’s community driven care which needs to be fixed. “Our biggest threat is not being able to get patients out at the other end, and patients who are medically able to leave but need care to thrive at home.”

That, along with a more efficiently run and widely used 111 service would, he thinks go a long way to relieving the pressure on emergency departments. "If we could have a culture where patients called 111 if they had a minor problem, and spoke to a GP who talked them through the options that exist elsewhere... we could deliver our resources in a much more efficient way."

It’s clear from talking to the staff here and watching a busy Friday night shift play out in front of me, with all its drama and hurdles, that they are absolutely passionate about emergency care. Which is not to say that other A&E departments aren’t equally invested. What may, they feel, be unique is the inclusive culture which the appointment of a new chief executive, Pauline Philip, in 2010 brought about, coupled with the simple fact that the vast majority of staff have worked here a very long time. Giovanna Healy, a lead nurse who has worked at the trust for 36 years, tells me she could never have considered working anywhere else. “We’re lucky because we have a core group of senior people that have been here for years. I can list all my staff and I’ve got about 90. Not many could say that.”

It would be short-sighted to assume that Luton and Dunstable is simply blessed with a relatively calm catchment area - its proximity to the airport and a major motorway ensure A&E is never quiet - or that it has received funding far beyond other hospitals. This is a department running on a knife edge, just like any emergency unit. But for some time now, it has kept its head just above water, and it plans to remain that way.